Open Operative Technique

The principles of successful surgery for reflux disease are entirely predicated on the creation of a valvular mechanism that will control the reflux of gastric acid into the lower esophagus. There should be a requisite emphasis on the correction of associated hiatal hernias because maintenance of the esophogagastric junction below the diaphragm greatly enhances the physiologic effects on the lower esophageal sphincter mechanisms. The transabdominal operation is best performed through an upper midline incision. Xiphoid excision may be of benefit in an occasional patient. Thorough exploration of the abdomen is performed, and the decision to address associated diseases is confirmed. Attention is then turned to the esophageal hiatus. The first maneuver is to mobilize the left lobe of the liver, to fold it upon itself, and to retract it to the patient's right with a Harrington retractor. A transverse incision of the anterior peritoneum over the gastroesophageal junction is made and converted into an inverted U. This is extended to the first short gastric vessels laterally and to the ascending branch of the left gastric artery medially ( Fig. 12-1 ). The operator's fingers may then be directed around the esophagus. Digital palpation should allow for identification of the diaphragmatic crura and the posterior vagus nerve. Both vagus nerves are included in the esophageal mobilization, and the structures are controlled with a Penrose drain. If substantial periesophageal inflammation persists, caution must be exercised to remain particularly wide of the esophagus to decrease the possibility of iatrogenic perforation. Palpation of the nasogastric tube or a No. 40 French Maloney bougie may facilitate the identification of the bounds of the esophagus. Esophageal mobilization is completed, usually via blunt dissection, and permits visualization of the diaphragmatic crura. We believe that crural repair is an essential part of the operation.

At this point, it is helpful to recognize the unique role of the bare area of the stomach to understand why a hiatal hernia is usually a true sliding hernia ( Fig. 12-2 ). The posterior gastric fundus is a retroperitoneal structure and usually is easily mobilized from the pancreas and other retroperitoneal tissues. This blunt dissection is relatively easily accomplished by working from the right side of the esophagus and along the lesser curvature above

Figure 12-1 Nissen fundoplication. After the liver is mobilized and retracted, a transverse incision of the anterior peritoneum is made over the gastroesophageal junction and is converted into an inverted U.

Figure 12-1 Nissen fundoplication. After the liver is mobilized and retracted, a transverse incision of the anterior peritoneum is made over the gastroesophageal junction and is converted into an inverted U.

Figure 12-2 Unique role of the bare area of the stomach.

Finger Suture Removal Time
Figure 12-4 Tightening of crural suture sufficient to allow room for index finger alongside the esophagus when the dilator has been removed.
Figure 12-6 Completion of wrapping of gastric fundus, after which the operator should be able to pass two fingers under the wrapped portion and along the bougie and the esophagus. L.G.A. = left gastric artery.
TABLE 12-3 -- Clinical Results of Fundoplication

Clinical Result

Was this article helpful?

0 0
Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

Get My Free Ebook


Post a comment